"Safe Airline" vs. Unsafe Culture. We're discussing the wrong thing!

[GlueBall]

chillpill . . .

On my last line check I was chided by a senior line-check airman for having come off the A/P & A/T "too early" during a vectored ILS approach in VMC at 4000 feet. His lecture was that I should have kept A/P & A/T engaged until at least AFTER intercept of localizer. He had reminded me that SOP required maximum use of automation in all phases of flight.

Four years ago I had declined extension of my check airman appointment because I did not (and still don't) agree with maximum automation philosophy. After many moons on the B74 and 20K+ hours, I'm still being lectured on new ways to fly this old bird. Ten years ago this was not so much an SOP issue.

The industry continues a dangerous trend away from manual piloting skills.

[Tee Emm]

Some time ago I discussed automation addiction with a 737 colleague. He related a recent experience of coming into Sydney NSW where the first officer was PF. They were cleared visually to intercept the ILS localiser and were approaching on an intercept angle of around 25 degrees 17 miles from the runway in clear weather. With the automatics still engaged, the F/O asked if she could disconnect the autopilot and hand fly as she had an instrument rating coming up and wanted to practice her hand flying. The captain had no problem with that.

ATC said clear for final. However the F/O continued using the autopilot. The captain suggested she turn off the autopilot and fly by hand - after all she had requested it in the first place. The F/O said she would leave the autopilot engaged for an automatic intercept until the 737 was established on final at about seven mile out. The captain queried this by saying if you want to practice hand flying then do so now. The F/O said she wasn't confident of being able to intercept the localiser by hand flying and would rather wait until the aircraft was established on the extended centre line.

Once on final (and fully visual in CAVOK), the F/O did the click click thing and started down on the glide path. The captain then suggested that if she was serious about hand flying down the ILS maybe she should switch off the flight director as well as the autothrottles and fly raw data. After all, the sun was shining and there was no wind.

The F/O said she wanted to leave the FD on in case of a go-around. The captain said you don't need a FD to conduct a GA. Nevertheless, the 3000 hour F/O was so underconfident of hand flying the 737 in perfect weather and field in sight that she stuck with the FD and auto throttles until very short final..

What a sad indictment of company procedures that some pilots are scared of hand flying raw data in good weather - let alone in clouds. These are indeed children of the magenta line. And there are captains like that, too.

[Agaricus bisporus]

Things have come to a pretty pass when "Professional" pilots are underconfident at flying an instrument approach manually in VMC and don't even consider it in IMC! I have watched the reluctance to fly manually in IMC creeping over the industry over the last 10 years or so with amazement but when so many Captains evidently disapprove of manual flying at all is it any wonder the new monoculture generation of FOs develop the thinking that it must be a slightly dodgy procedure that really isn't the right thing to do - and certainly not if you can't see where you're going...

I reckon FOs ask me if they can handfly once, maybe twice a month, 20 days work per month, that's 10% OF FOs max (3% of sectors) Plus - I am not one of the discouragers, quite the opposite! However, you do have to think of pax comfort and when you're being hoiked around with the coffee spilling on a heavy handed approach you do wonder if the automatics aren't there for a reason!

This is yet another example of how strange and unintended deviations develop in a monoculture.

In another 5-10 years we'll have an entire generation of pilots who never think of manual flight at all and will do all they can to prevent it.

The bean-counters' inclination after the Aasiana problem will be to further regulate manual flying.
The training system will try to improve it.
The safety officer will see that more rules go into the book about it.
The manufacturer will add more automated protection to counter human failings.
The one man and a dog cockpit is getting ever closer, isn't it?

[16024]

Just to play devils advocate for a bit: I do find myself hand flying less than I used to, and ironically it's because of the safety culture! With most airlines AFM saying something along the lines of: "the regulations say you must be stable at 500 but we want you stable at 1000", and most busy airports demanding 16024 (hey, hey!) that gives little margin for error. My own company takes no prisoners if you don't have it nailed by 1000, so there's a lot going on in one mile there.
And returning reluctantly to the plog+ uplift part of the debate, BOAC says in post 10 that most AFMs make no mention of when to divert, before going back to telling everybody how unprofessional they are. Well I had a bit of an old browse through my last 3 company part As and they all say something very similar: take account of traffic and weather where you are, where you might end up, and all points in between, to make sure you get there with enough fuel. Paraphrasing, of course but that's about it. You don't even need a********p or common sense.
You do need enough fuel to begin with, though...

[BOAC]

Originally Posted by 16024

Well I had a bit of an old browse through my last 3 company part As

- I bet none of them tell you not to stay in the hold until near CMR, though, do they?

telling everybody how unprofessional they are

- Hmm - cannot see that line, old chap. I did say that I thought they made mistakes in when to divert, but not that they were 'unprofessional'. Assuming you are, you should know that even 'professionals' are allowed mistakes here and there. I actually think they handled events quite 'professionally' given the cards they were dealt.

[PAXboy]

south coast

Posters keep coming back to the 'pressure' not to carry extra fuel, but I see little factual evidence of what happens to someone who puts the safety of the plane ahead of that memo which would always be defended by the company as an instruction not to incur unnecessary costs while not compromising safety.

So, can anyone offer any evidence of actual negative action against someone who basically deviates from the memo because he/she felt safety would be compromised if extra fuel wasn't taken?

Ah, but if it could be proved then the mgmt would have used a different method! Sorry to sound so suspicious but, having worked in many other lines of commerce and loval govt (but not airlines) for over 35 years, I know how difficult it is to prove this.

The whole point is that months/years of a 'raised eyebrow' and 'a certain tone of voice' are not in the HR rule book. We know from personal friendships and relationships how we learn what others want and do not want - without them being specific. So it is at work.

You also notice that a particularly good pilot/staff member is passed over for promotion - and you know that good person is one that you'd trust with your life. Then you see some 'flash harry' get promoted ahead of his time and everyone knows that he's an @rse licker. In commerce it happens every day and it's happened to me because I was too independently minded. People can get fired, made redundant or moved sideways or 'promoted' to a job that will ensure they leaves. It is an everyday event.

But in your world, the Seniority method of promotion means that mgmt have to find other ways of promoting the ones who do what they are told. From what I read (in this thread and elsewhere) the selection criteria is where these decisions are being made.

By way of pertinent illustration of my expressed view (post #41)

Only two things will change the Normalisation of Deviance and the complacency of men: Death and Money.

See: BBC News - Bank of America intern death sparks debate over hours
Someone has died and NOW there is a debate. QED.

[fireflybob]

Slightly off the thread but still very relevant to this debate it's worth listening to the clip from Matthew Syed below (starts at 14.20). His book "Bounce" is a good read where he talks about the "myth of talent and the power of practice".

Another good read allied to this is "Outliers" by Malcolm Gladwell where he argues (correctly in my opinion, backed up by various stories and case studies) that to become really competent at anything you have to do (at least) 10,000 hours experience but not just "any" experience but one of constant and never ending improvement by way of mentoring etc.

Returning to the issue of safety and skilled/competent pilots, pilots who cut their teeth on basic jets (round dial instruments, no EFIS, no autothrottle, basic autopilot etc) and have done thousands of hours hand flying same are "hard wired" for manual flight. They may be a little rusty but it's no big issue to disengage the automatics and hand fly if they are forced to do so by either system failures or choose to do so as a better option. The new generation of pilots lack the skills to confidently hand fly the a/c in all situations simple because they have not had the practice over thousands of hours flying. How we address this conundrum is a pressing issue for the airline industry.

Here is the link - (start at 14.20):

Matthew Syed

[Sober Lark]

Do you think an airlines risk management culture has become more influenced by margins than by safety? Your fuel example appears to be an acceptable (to management at least) residual risk.

[BARKINGMAD]

COSTING MY A*SE.

"Do you think an airlines risk management culture has become more influenced by margins than by safety? Your fuel example appears to be an acceptable (to management at least) residual risk." asks Sober Lark.

Read pages 161/162 of the UAE 744F accident report and then ponder your question.

It would appear that "Flight Safety is NO Accident" no longer applies, and our eventual demise, possibly along with the unfortunate SLF, has been costed and risk analysed to be acceptable at a certain rate?!

[Irish Steve]

It would appear that "Flight Safety is NO Accident" no longer applies, and our eventual demise, possibly along with the unfortunate SLF, has been costed and risk analysed to be acceptable at a certain rate?!

I am going to put up some thoughts, some possibly very provocative, and some that I am not going to get drawn on in depth in order to avoid lots of problems, and I am not saying I have answers to some of the issues, but they are ( I think) all part of the scenario that the original poster was trying to raise 80 some messages ago.

The quote above is nothing new, the underlying reason being that the bean counters that perform the calculation are never anywhere near the scene of the accident, or the grieving relatives, or the recriminations that reverberate around the company for a long time after an "acceptable risk" incident.

I've just read the thread. and I'm going to try to put a few other thoughts back into the arena.

Standard Operating Procedures are exactly what that says. STANDARD. If the aircraft has a crew that has lived by the magenta line for a long time, what do they do, and how do they do it, when faced with a scenario that is not covered by SOP's? If things have suddenly gone very pear shaped, trying to determine if the scenario is covered by SOP's or not, before even acting may well be the first danger. Having an adequate knowledge of the aircraft and its systems is then the next requirement.

In too many situations, slavish reliance on ever increasingly complex SOP's has become the replacement for knowledge and skill. Is that because of the changes in the skill levels of the people coming in? For many years, the core of aviation flight crew were the people that had "retired" from (often compulsory) military service, and for the military, training costs were not an issue, they did whatever it took to produce the required result. Now, that route does not have the same throughput, so a new way to produce the people with the skills is required. Do the new systems produce the skills in the way that is required?

Are there flight training organisations that have Instructors who are pilots for a carrier, but fly (and are paid) without logging their "instructing" hours to avoid "difficulties" with their employer or the relevant regulator in terms of rest periods, maximum duty time, things like that?

A good few years ago, one of the airlines I did some work with replaced the senior training captains in the simulator with relatively low time first officers as the simulator operator/instructor. Was that a good move, or did it hasten the decline in the skills that were passed on to the next generation of pilots, in that the younger first officers were probably unaware of the gotchas that the aircraft was capable of, so didn't modify their scenarios to include the gotchas in the training pattern.

A long time ago, I was working on a research project with a major manufacturer on human factors on the flight deck. In order to make the simulation as realistic as possible, we needed to do some research on manual reversion on the A320, which is one of those thing that according to a recent CH 4 program can't happen easily, as there are 5 computers that all have to fail before it reaches desperation point. We visited a simulator in Europe, and tried some of the pre determined scenarios that were part of getting the information we needed. We had to abandon the research in that area at that simulator, as it transpired that "the statistical analysis of the chances of that scenario occuring is so low, it does not form part of our training" The scenario that we could not perform was an approach and landing in manual reversion, but the simulator we were using was not stable in straight and level flight, if disrupted into phugoids, instead of reverting over time to stable flight, it departed stable flight and became unrecoverable. Not what we expected, and not what we were given to understand was the performance of the aircraft. On investigating further we were told "the chances of it happening are so low, it it does happen, the chances of a successful landing are also so low, there's no point spending a lot of time and money training for it, so the flight model does not accurately replicate that area of the envelope"

We found a simulator in North America that was capable of being operated to the level we needed, and went over and did our research which ended up being incorporated into the flight model of the device, and also came out with some interesting results, but that's another story for another time, a non type rated crew performed a manual reversion go around, which supposedly wasn't possible.

Is it acceptable that for economic reasons, pilots are not trained in all aspects of handling the aircraft in degraded mode?


In another but related area, SOP's and the complexity of the problems meant that a heavy and skilled crew had to spend a very long time working checklists after the uncontained engine failure on the A380.
Given the degree of structural damage, and the other damage, would the outcome have been the same if the weather in the area of the accident had been significant CB activity, or the edge of a typhoon, or similar, or would the outcome have been a possibly catastrophic structural failure before they finished working through the seemingly endless check list problems?

Is it right or appropriate for an airline to harass a web site operator for posting factual reports about aviation incidents that have no editorial slant, or "journalistic licence", and have been verified from multiple sources. To avoid any doubt, the site I am referring to is "Aviation Herald", which is VERY selective in the manner of reporting, and does not cover general aviation or non reportable incidents. They received strong legal threats from a low cost carrier as a result of publishing information from regulators that was in the public domain. Is that the way that a safety conscious airline should be operating? (while I know the operator, I have no involvement with Aviation Herald)

Behind the scenes, it's reaching the stage where an aircraft is deemed unable to fly until the weight of the paperwork is equal to the weight of the airframe, and increasingly, the right piece of paper with the right rubber stamp on it is deemed more essential than the skill and experience of the people carrying out the task. Trying to make sense of a Continuing Airworthiness Maintenance exposition is reaching the point where the easiest way to describe is is bull***t baffling brains, but in too many cases, its another example of bean counters covering their vulnerable anatomy from being kicked by anyone.

Effective supervision should mean more than a tired and hard pressed supervisor putting his rubber stamp on 20 different lines on a piece of paper, yes, the paperwork trail is perfect, but does that mean the task has been correctly completed?

On another occasion,.as the ramp agent handling the flight, I stopped a Malev 737 from departing after a night stop until I had a satisfactory explanation of why the alternate static ports were covered by aluminium speed tape. Turned out it has flown like that for 2 days after an airframe wash at home base. The worrying thing was the response of the management after the event, it was made very clear to me that if anything was put in writing, the repercussions would not be good. It should have been an MOR to the relevant AA, but it didn't happen.

There are other areas, but I'm not going there now, the main aim is to try and put the focus of thought back on to the underlying issues that are becoming of increasing concern to some inside the industry.

In some respects, I'm happy that I am now too old to be in a seat at the sharp end of a modern airliner, some of the changes that have happened over the last 30 years that I've been associated with aviation are not as comfortable as I would like them to be.

[Centaurus]

I have kept a daily diary all of my flying career from when I first flew a Mustang when I was 21, to when I was forced to retire from airline flying due age 60 rule a long time ago. The majority was on the 737-200 where hand flying was normal until it was time to plug in the automatic pilot at 15,000 ft on the climb and again disconnect at 15,000 on descent. No LNAV or VNAV - just INS,NDB/ILS and VOR and profile descent DME v height. In those days these were considered as normal pilot skills. And best of all we enjoyed the flying and the knowledge and confidence we could hack it.

It was when I first flew the 737 Classics with a European charter operator 25 years ago, that I met my first example of automatic addiction and that was among the cadet first officers with whom I flew. Some had only 250 hours in their log books and yet they were legally second in command with all that entailed if something happened to me. Nice chaps all - but almost totally addicted even then to button pushing because that was what they were taught in the simulator and line flying.

I well remember when somewhere over Europe on a fine day I decided to disconnect the automatics at 31,000 ft and practice hand flying following a VOR radial.

The F/O was staggered and got all tensed up and even said he would have to put his shoulder harness on because I was hand flying! I told him not to be so bloody stupid. But the poor bugger was genuinely frightened of manual flying above flaps up speed. ... Shades later of the Air France A330 loss of control into the Atlantic.

That was all those years ago and we still read about the potential dangers of automation addiction. My old diary notes recorded regular observations of automation addiction so there is no embellishment of what I saw at first hand. Being still involved with flight training (simulators) I am quite convinced that nothing will ever change and that automation dependency is here for good.

When the first glass cockpits came along, some wit observed that he could now type at 80 words a minute, but he couldn't fly for nuts. 40 years later things haven't changed much.

Despite published accident reports indicating pilots' poor instrument flying ability has been the cause of fatal unusual attitudes in IMC, there has been no serious attempts by aircraft manufactures or airlines to improve or encourage basic manual instrument flying skills to counter the clear lack of basic handling ability in IMC that has characterised todays flight decks. Lip service maybe - but that's about all. Even visual approaches in fine weather are cause for alarm in some ethnic cultures. The Asiana 777 crash at SFO is a case in point.

The pendulum will never again swing back to the days when pilots were real pilots and not autopilot data input managers. My advice to those (including me) who continually bemoan the steady march of still more sophisticated and pilot-proof automation is to accept that is the way of the future. Time to get a life and read a good book instead of worrying needlessly about automation dependency.

As a Boeing 787 designer told one of his simulator instructors (and believe me it is a true story) "The 787 was designed on the assumption it will be flown by incompetent pilots". That says it all....

[Sober Lark]

Barkingmad, thanks for referring me to p161/162 of the N571UP final report. The figures mentioned are all part of the statistical measurement of risk data. Risks for all airlines have to be quantified, measurements have to be made, data described and forecasts made and anyone involved in insurance cannot escape the need to use such numbers. Based on this an appropriate insurance premium is charged and cover provided. Insurance is based on the possibility of an event happening within the period of cover. If the event was a certainty then it probably wouldn't be insurable.